Letters

Universal coverage concerns

To the Editor:

Universal coverage for all Americans with a basic health plan is a laudable goal for the most part, but I have serious reservations about a couple tenets of the AAFP's draft health care coverage proposal. [See the November/December 2000 Editor's Page, "How Do You Like Your Universal Coverage?" page 11.]

Having all businesses contribute to the financing of the coverage certainly seems equitable but will most likely cripple many small and start-up businesses operating on thin profit margins. Also, the states are rapidly wasting tobacco-settlement money on various programs not related to health care with nary a whimper from organized medicine. Why should we expect this money to be used correctly?

Having worked in two health care systems that saw patients without co-pays, I know that utilization will increase if there are no co-pays. However, there should be some direct cost to the patient for a service provided; otherwise our time and skills mean nothing to them.

Finally, having worked directly with patients covered by the Oregon Health Plan, I can assure you that it has not lived up to its utopian ideal. It's currently plagued with financial problems and has difficulty finding providers to take its patients. This will only worsen as medicine becomes more expensive and consumes a larger portion of each year's state budget.

J.M. Grubbs, MD
Longview, Wash.

No-win coding

To the Editor:

As I read the article "Understanding Medicare's Mental Health Treatment Limitation" [Getting Paid, November/December, page 15], I became even more convinced that I'll never get paid for mental health services without being devious and "gaming the system."

The senior citizens in my practice won't come in for psychotherapy visits. They will come in if the visit is for a medical concern -- even though I may spend a lot of the visit on the patient's mental health needs. If I then code the visit based on what actually transpired, Medicare will reduce payment. If I ask the patient for the difference, I'll be told that Medicare will pay for treatment of the illness. To date, I've accepted financial losses in an effort to do the best for my patients, but it just keeps getting harder.

Alan Levin, MD
Philadelphia

Rx advertisements

To the Editor:

As physicians, we're faced with a steadily growing problem -- prescription medication television advertisements. Besides the inconveniences that come with patients asking physicians for particular drugs, perhaps the most serious consequence of this practice is the added cost of medications due to the price of television time. Most patients today complain about the high price of prescriptions, which leads many to make periodic trips to Mexico to buy their medicine -- medicine made by the same companies but at a considerably lower price.

Having worked for a large pharmaceutical company in the past, I offer a simple solution to this growing practice: We should simply refuse to see the company's representatives until they stop this growing tendency. We owe this to our patients who are unaware of the negative effects of this menace.

As Edmund Burke said, "The only thing necessary for the triumph of evil is for good men to do nothing."

John F. Smyth, MD
Col. Polanco, Mexico

Is this quality?

To the Editor:

I'm sure quality improvement is an excellent thing for a practice to do. I've advocated for it for most of my admittedly short time (11 years) in practice. But I'm concerned about the apparently gratuitous attacks on insurers made in the article "Making Quality and Service Pay: Part 1, The Internal Environment" [October 2000, page 48]. I'm no fan of the current health care insurance system (or nonsystem), but I'm not sure quality improvement should be based on what insurers will or will not pay. Some of the suggestions just seem to get around insurance companies rather than improve quality.

Dannen Mannschreck, MD
Beaumont, Texas

Author's response:

I believe Dr. Mannschreck misinterpreted our article. It was not a gratuitous attack on insurers. The article described how practices can incorporate innovations into care even when they're not reimbursed. It discussed how several new, nonreimbursed care methods can help improve practice finances, and a case study was provided to that effect.

Part 2 of the series ["Making Quality and Service Pay: Part 2, The External Environment," November/ December 2000, page 25] described how some insurers are beginning to change their payment methods in order to reimburse both higher quality care and some new forms of care. Again, case studies were provided.

The articles taken together deliver a specific message: In order to improve both the quality of our care and our service, we need to find fiscally responsible ways of doing so. That requires both physician leadership and insightful insurance partners working toward shared goals of higher quality, better service health care. Examples of this exist today, and we're encouraged that they will continue to proliferate.

Charles M. Kilo, MD, MPH
Portland, Ore.

Off the mark

To the Editor:

As a physician who recently reviewed over 25 electronic medical records systems before purchasing one, I think FPM's recent survey ["Electronic Medical Records: The FPM Vendor Survey," January 2001, page 45] missed some key points.

Features don't necessarily equate to functionality in an EMR. Just because a product can do something doesn't mean it can be done easily, or that it needs to be done at all. The authors themselves pointed out that this survey was not scientific, but I think more could have been made of the fact that it was based on vendor-reported details and not on analysis by physicians who are actually using these products.

A4 Health Systems, the vendor of my EMR, HealthMatics, must have responded conservatively and was in many ways misrepresented. In their case it was like trying to put a square peg into a round hole -- the categories missed some of the attributes that led me to buy their system. I made my selection based not only on features but on how the vendor understood the physician office environment. Many EMRs boast a lot of bells and whistles, but all that really counts is the impact on workflow and the product's ease of use.

I chose the HealthMatics EMR for the following reasons:

• It has the ingredients to run a completely paperless office.
• It uses a desktop that shows today's schedule, the patients waiting and the presenting charts that have been pulled.
• It has an option to search data.
• It allows pre-defined dosages for medications.
• It has customizable templates.
• It has an intuitive evaluation and management (E/M) coding calculator that uses risk tables and rationalizes coding levels.
• It tracks all changes made after a chart is signed off.

There's a lot of technology out there gathering dust because it just can't be used in real life. In order to properly rank EMRs, you should talk to physicians who are using the EMR you're interested in, view a live demo and, as the authors said, use feature surveys only as a starting point.

Pat Coates, DO
Garland, Texas

Corrections

An answer in "Coding and Documentation" [July/August 1999, page 12] gave incorrect advice regarding use of the CPT codes for prolonged services. The amount of time that CPT indicates is typically associated with the level of office visit provided should be subtracted from the time actually spent in face-to-face contact with the patient. The result of that calculation should guide the selection of the prolonged services code. For an example, see "Calculating prolonged services" on page 23.

In "The Family Practice Management Practice Self-Test," [February 2001, page 41], we inadvertently failed to acknowledge the considerable contributions of Marc L. Rivo, MD, MPH, medical editor of FPM, to the development of the self-test. Our apologies, Dr. Rivo!

We want to hear from you. Letters is an open forum for our readers. Write to Letters Editor, Family Practice Management, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-6272. If you prefer, fax your letter to 913-906-6010. You may also contact FPM by e-mail at fpmedit@aafp.org. Include your address, daytime phone number and fax number, if any. Letters may be edited for length and style. All letters sent to the editors of FPM are presumed to be intended for publication unless otherwise specified in the text of the letter. Submission of a letter constitutes transfer of the copyright to the AAFP.

Copyright © 2001 by the American Academy of Family Physicians.
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